How to stop smoking in pregnancy and following childbirth - NICE public health guidance 26
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Issue Date: June 2010 How to stop smoking in pregnancy and following childbirth NICE public health guidance 26
NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
NICE public health guidance 26
How to stop smoking in pregnancy and following childbirth
Ordering information
You can download the following documents from
www.nice.org.uk/guidance/PH26
The NICE guidance (this document) which includes all the
recommendations, details of how they were developed and evidence
statements.
A quick reference guide for professionals and the public.
Supporting documents, including an evidence review and an economic
analysis.
For printed copies of the quick reference guide, phone NICE publications on
0845 003 7783 or email publications@nice.org.uk and quote N2198.
This guidance represents the views of the Institute and was arrived at after
careful consideration of the evidence available. Those working in the NHS,
local authorities, the wider public, voluntary and community sectors and the
private sector should take it into account when carrying out their professional,
managerial or voluntary duties.
Implementation of this guidance is the responsibility of local commissioners
and/or providers. Commissioners and providers are reminded that it is their
responsibility to implement the guidance, in their local context, in light of their
duties to avoid unlawful discrimination and to have regard to promoting
equality of opportunity. Nothing in this guidance should be interpreted in a way
which would be inconsistent with compliance with those duties.
National Institute for Health and Clinical Excellence
MidCity Place
71 High Holborn
London
WC1V 6NA
www.nice.org.uk
© National Institute for Health and Clinical Excellence, 2010. All rights reserved. This material
may be freely reproduced for educational and not-for-profit purposes. No reproduction by or
for commercial organisations, or for commercial purposes, is allowed without the express
written permission of the Institute.
Page 2 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Introduction
The Department of Health (DH) asked the National Institute for Health and
Clinical Excellence (NICE) to produce public health guidance on interventions
aimed at stopping smoking in pregnancy and following childbirth.
The guidance is for NHS and other commissioners, managers and
practitioners who have a direct or indirect role in, and responsibility for,
helping women to stop smoking in pregnancy and following childbirth. This
includes those working in: local authorities, education and the wider public,
private, voluntary and community sectors. It may also be of interest to women
who are planning a pregnancy, those who are pregnant and those who
already have children, as well as their partners and families and other
members of the public.
This guidance will complement, but will not replace, other NICE guidance on
smoking prevention and cessation as well as guidance on identifying and
supporting people most at risk of dying prematurely and behaviour change.
(For further details, see section 7.) This guidance updates recommendations
on smoking in NICE's clinical guideline on antenatal care.
The Public Health Interventions Advisory Committee (PHIAC) developed
these recommendations on the basis of reviews of the evidence, economic
modelling, expert advice, stakeholder comments and fieldwork.
Members of PHIAC are listed in appendix A. The methods used to develop
the guidance are summarised in appendix B.
Supporting documents used to prepare this document are listed in appendix
E. Full details of the evidence collated, including fieldwork data and activities
and stakeholder comments, are available on the NICE website, along with a
list of the stakeholders involved and NICE’s supporting process and methods
manuals. The website address is: www.nice.org.uk
This guidance was developed using the NICE public health intervention
process.
Page 3 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Page 4 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Contents
1 Recommendations .................................................................................... 6
2 Public health need and practice .............................................................. 21
3 Considerations ........................................................................................ 24
4 Implementation ....................................................................................... 26
5 Recommendations for research .............................................................. 27
6 Updating the recommendations .............................................................. 28
7 Related NICE guidance .......................................................................... 28
8 Glossary.................................................................................................. 28
9 References ............................................................................................. 29
Appendix A: membership of the Public Health Interventions Advisory
Committee (PHIAC), the NICE Project Team and external contractors ......... 31
Appendix B: summary of the methods used to develop this guidance ........... 36
Appendix C: the evidence .............................................................................. 44
Appendix D: gaps in the evidence.................................................................. 55
Appendix E: supporting documents ............................................................... 57
Page 5 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
1 Recommendations
This is NICE’s formal guidance on how to stop smoking in pregnancy and
following childbirth. When writing the recommendations, the Public Health
Interventions Advisory Committee (PHIAC) (see appendix A) considered the
evidence of effectiveness (including cost effectiveness), commissioned
reports, expert testimony, fieldwork data and comments from stakeholders
and experts. Full details are available at www.nice.org.uk/guidance/PH26
The evidence statements underpinning the recommendations are listed in
appendix C.
The evidence reviews, supporting evidence statements and economic
modelling report are available at www.nice.org.uk/guidance/PH26
Background
Helping pregnant women who smoke to quit involves communicating in a
sensitive, client-centred manner, particularly as some pregnant women find it
difficult to say that they smoke. Such an approach is important to reduce the
likelihood that some of them may miss out on the opportunity to get help.
The recommendations in this guidance which refer to NHS Stop Smoking
Services also apply to other, non-NHS services that offer help to quit and
operate to the same standard.
NHS Stop Smoking Services are local services funded by the Department of
Health to provide accessible, evidence-based and cost-effective support to
people who want to stop smoking. The professionals involved may include
midwives who have been specially trained to help pregnant women who
smoke to quit.
Effective interventions
The recommendations mainly cover interventions to help pregnant women
who smoke to quit. These are listed at the beginning of recommendations 4
and 5. Interventions for partners are covered in recommendation 7.
Page 6 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Interventions that are effective with the general population are described in:
‘Brief interventions and referral for smoking cessation’ (NICE public health
guidance 1), ‘Workplace interventions to promote smoking cessation’ (NICE
public health guidance 5) and ‘Smoking cessation services’ (NICE public
health guidance 10).
No specific recommendations have been made for those planning a
pregnancy or who have recently given birth. This is due to the lack of
evidence available on stop-smoking interventions for these groups. It does not
constitute a judgement on whether or not such interventions are effective or
cost effective.
Whose health will benefit?
These recommendations should benefit women who smoke and who:
are planning a pregnancy
are already pregnant
have an infant aged under 12 months.
They should also benefit the unborn child of a woman who smokes, any
infants and children she may have, her partner and others in her household
who smoke.
Recommendation 1 Identifying pregnant women who smoke
and referring them to NHS Stop Smoking Services – action for
midwives
Context
Some women find it difficult to say that they smoke because the pressure not
to smoke during pregnancy is so intense. This, in turn, makes it difficult to
ensure they are offered appropriate support.
A carbon monoxide (CO) test is an immediate and non-invasive biochemical
method for helping to assess whether or not someone smokes. However, it is
unclear as to what constitutes the best cut-off point for determining smoking
Page 7 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
status. Some suggest a CO level as low as 3 parts per million (ppm), others
use a cut-off point of 6–10 ppm.
It is important to note that CO quickly disappears from expired breath (the
level can fall by 50% in less than 4 hours). As a result, low levels of smoking
may go undetected and may be indistinguishable from passive smoking.
Conversely, environmental factors such as traffic emissions or leaky gas
appliances may cause a high CO reading – as may lactose intolerance.
When trying to identify pregnant women who smoke, it is best to use a low
cut-off point to avoid missing someone who may need help to quit.
Who should take action?
Midwives (at first maternity booking and subsequent appointments).
What action should they take?
Assess the woman’s exposure to tobacco smoke through discussion and
use of a CO test. Explain that the CO test will allow her to see a physical
measure of her smoking and her exposure to other people’s smoking. Ask
her if she or anyone else in her household smokes. To help interpret the
CO reading, establish whether she is a light or infrequent smoker. Other
factors to consider include the time since she last smoked and the number
of cigarettes smoked (and when) on the test day. (Note: CO levels fall
overnight so morning readings may give low results.)
Provide information (for example, a leaflet) about the risks to the unborn
child of smoking when pregnant and the hazards of exposure to
secondhand smoke for both mother and baby. Information should be
available in a variety of formats.
Explain about the health benefits of stopping for the woman and her baby.
Advise her to stop – not just cut down.
Explain that it is normal practice to refer all women who smoke for help to
quit and that a specialist midwife or adviser will phone and offer her
Page 8 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
support. (Note: a specialist adviser needs to offer this support to minimise
the risk of her opting out.)
Refer all women who smoke, or have stopped smoking within the last 2
weeks, to NHS Stop Smoking Services. Also refer those with a CO reading
of 7 ppm or above. (Note: light or infrequent smokers should also be
referred, even if they register a lower reading – for example, 3 ppm.) If they
have a high CO reading (more than 10 ppm) but say they do not smoke,
advise them about possible CO poisoning and ask them to call the free
Health and Safety Executive gas safety advice line on: 0800 300 363.
Use local arrangements to make the appointment and, in case they want to
talk to someone over the phone in the meantime, give the NHS Pregnancy
Smoking Helpline number: 0800 1699 169. Also provide the local helpline
number where one is available.
If her partner or others in the household smoke, suggest they contact NHS
Stop Smoking Services. If no one smokes, give positive feedback.
At the next appointment, check if the woman took up her referral. If not, ask
if she is interested in stopping smoking and offer another referral to the
service.
If she accepts the referral, use local arrangements to make the
appointment and give the NHS Pregnancy Smoking Helpline number: 0800
1699 169. Also provide the local helpline number where one is available.
If she declines the referral, accept the answer in an impartial manner,
leave the offer of help open. Also highlight the flexible support that many
NHS Stop Smoking Services offer pregnant women (for example, some
offer home visits).
If the referral was taken up, provide feedback. Review at subsequent
appointments, as appropriate.
Page 9 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Where appropriate, for each of the stages above record smoking status,
CO level, whether a referral is accepted or declined and any feedback
given. This should be recorded in the woman’s hand-held record. If a
hand-held record is not available locally, use local protocols to record this
information.
Page 10 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Page 11 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Recommendation 2 Identifying pregnant women who smoke
and referring them to NHS Stop Smoking Services – action for
others in the public, community and voluntary sectors
Who should take action?
Those responsible for providing health and support services for the target
group of women. This does not include midwives (see recommendation 1). It
does include:
GPs, practice nurses, health visitors and family nurses.
Obstetricians, paediatricians, sonographers and other members of the
maternity team (apart from midwives).
Those working in youth and teenage pregnancy services, children’s
centres and social services.
Those working in fertility clinics, dental practices, community pharmacies
and voluntary and community organisations.
What action should they take?
Use any appointment or meeting as an opportunity to ask women if they
smoke. If they do, explain how NHS Stop Smoking Services can help
people to quit and advise them to stop.
Offer those who want to stop a referral to NHS Stop Smoking Services.
Use local arrangements to make a referral. Record this in the hand-held
record. If a hand-held record is not available locally, use local protocols to
record this information.
Give the NHS Pregnancy Smoking Helpline number in case they want to
talk to someone over the phone in the meantime: 0800 1699 169. Also
provide the local helpline number where one is available.
Page 12 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Those with specialist training should provide pregnant women who smoke
with information (for example, a leaflet) about the risks to the unborn child
of smoking when pregnant. They should also provide information on the
hazards of exposure to secondhand smoke for both mother and baby and
on the benefits of stopping smoking. Information should be available in a
variety of formats.
Recommendation 3 NHS Stop Smoking Services – contacting
referrals
Who should take action?
NHS Stop Smoking Services specialist advisers.
What action should they take?
Telephone all women who have been referred for help. Discuss smoking
and pregnancy and the issues they face, using an impartial, client-centred
approach. Invite them to use the service. If necessary (and resources
permitting), ring them twice and follow-up with a letter. Advise the
maternity booking midwife of the outcome.
Attempt to see those who cannot be contacted by telephone. This could
happen during a routine antenatal care visit (for example, when they
attend for a scan).
Address any factors which prevent the women from using smoking
cessation services. This could include a lack of confidence in their ability to
quit, lack of knowledge about the services on offer, difficulty accessing
them or lack of suitable childcare. It could also include a fear of failure and
concerns about being stigmatised.
If women are reluctant to attend the clinic, consider providing structured
self-help materials or support via the telephone helpline. Also consider
offering to visit them at home, or at another venue, if it is difficult for them
to attend specialist services.
Page 13 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Send information on smoking and pregnancy to those who opt out during
the initial telephone call. This should include details on how to get help to
quit at a later date. Such information should be easily accessible and
available in a variety of formats.
Recommendation 4 NHS Stop Smoking Services – initial and
ongoing support
Context
Studies have shown that the following interventions are effective in helping
women who are pregnant to quit smoking:
cognitive behaviour therapy
motivational interviewing
structured self-help and support from NHS Stop Smoking Services.
In addition, in other countries the provision of incentives to quit has been
shown to be effective with this group (research is required to see whether it
would work in the UK).
Interventions using a ‘stages of change’ approach have had mixed success.
(In some studies the approach was effective, in others it was no better than
the control.) Giving pregnant women feedback on the effects of smoking on
the unborn child and on their own health (such as reports of urinary cotinine
levels) is not effective.
Who should take action?
NHS Stop Smoking Services specialist advisers.
What action should they take?
During the first face-to-face meeting, discuss how many cigarettes the
woman smokes and how frequently. Ask if anyone else in the household
smokes (this includes her partner if she has one).
Provide information about the risks of smoking to an unborn child and the
benefits of stopping for both mother and baby.
Page 14 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Address any concerns she and her partner or family may have about
stopping smoking and offer personalised information, advice and support
on how to stop1.
If partners or other family members are present at the first face-to-face
meeting, encourage those who smoke to quit. If they smoke but are not at
the meeting, ask the pregnant woman to suggest they contact NHS Stop
Smoking Services and provide her with contact details (for example,
telephone and address card).
Provide the woman with intensive and ongoing support (brief interventions
alone are unlikely to be sufficient) throughout pregnancy and beyond. This
includes regularly monitoring her smoking status using CO tests. The latter
may encourage her to try to quit – and can also be a useful way of
providing positive feedback once a quit attempt has been made.
Biochemically validate that the woman has quit on the date she set and 4
weeks after. Where possible, use urine or saliva cotinine tests, as these are
more accurate than CO tests and can detect exposure over the past few
days rather than hours. When carrying out these tests, check whether the
woman is using nicotine replacement therapy (NRT) as this may raise her
cotinine levels. Note: no measure can be 100% accurate. Some people
may smoke so infrequently – or inhale so little – that their intakes cannot
reliably be distinguished from that due to passive smoking.
If the woman says that she has stopped smoking, but the CO test reading
is higher than 10 ppm, advise her about possible CO poisoning and ask her
to call the free Health and Safety Executive gas safety advice line on: 0800
300 363. However, it is more likely that she is still smoking and any further
questions must be phrased sensitively to encourage a frank discussion.
1
This is an edited extract from a recommendation that appears in ‘Smoking cessation
services’ NICE public health guidance 10. It does not constitute a change to the original
recommendation.
Page 15 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
If she stopped smoking in the 2 weeks prior to her maternity booking
appointment, continue to provide support, in line with the recommendations
above and NHS Stop Smoking Services practice protocols.
Record the method used to quit smoking, including whether or not she
received help and support. Follow up 12 months after the date she set to
quit.
Establish links with contraceptive services, fertility clinics and
ante- and postnatal services so that everyone working in those
organisations knows about local NHS Stop Smoking Services. Ensure they
understand what these services offer and how to refer people to them.
Recommendation 5 Use of NRT and other pharmacological
support
Context
There is mixed evidence on the effectiveness of NRT in helping women to
stop smoking during pregnancy. The most robust trial to date has found no
evidence that it is effective (or that it affects the child’s birthweight). In
addition, there are insufficient data to form a judgement about whether or not
NRT has any impact on the likelihood that a child will need special care or will
be stillborn.
Who should take action?
NHS Stop Smoking Services.
What action should they take?
Discuss the risks and benefits of NRT with pregnant women who smoke,
particularly those who do not wish to accept other help from NHS Stop
Smoking Services. Use only if smoking cessation without NRT fails. If they
Page 16 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
express a clear wish to receive NRT, use professional judgement when
deciding whether to offer a prescription2.
Only prescribe NRT for use once they have stopped smoking (they may set
a particular date for this)3. Only prescribe 2 weeks of NRT for use from the
day they agreed to stop. Only give subsequent prescriptions to women who
have demonstrated, on re-assessment, that they are still not smoking4.
Advise pregnant women who are using nicotine patches to remove them
before going to bed4.
Neither varenicline or bupropion should be offered to pregnant or
breastfeeding women5.
Recommendation 6: NHS Stop Smoking Services – meeting
the needs of disadvantaged pregnant women who smoke
Who should take action?
NHS Stop Smoking Services.
What action should they take?
Ensure services are delivered in an impartial, client-centred manner. They
should be sensitive to the difficult circumstances many women who smoke
find themselves in. They should also take into account other
sociodemographic factors such as age and ethnicity and ensure provision
2
This is an edited extract from a recommendation that appears in ‘Smoking cessation
services’ NICE public health guidance 10. It does not constitute a change to the original
recommendation.
3
The British National Formulary (2010) advises on use of NRT during pregnancy: ‘Intermittent
therapy is preferable but avoid liquorice-flavoured nicotine products’.
4
This is an edited extract from a recommendation that appears in ‘Smoking cessation
services’ NICE public health guidance 10. It does not constitute a change to the original
recommendation.
5
This is an edited extract from a recommendation that appears in ‘Smoking cessation
services’ NICE public health guidance 10. It does not constitute a change to the original
recommendation.
Page 17 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
is culturally relevant. This includes making it clear how women who are
non-English speakers can access and use interpreting services6.
Involve these women in the planning and development of services6.
Ensure services are flexible and coordinated. They should take place in
locations – and at times – that make them easily accessible and should be
tailored to meet individual needs6.
Collaborate with the family nurse partnership pilot and other outreach
schemes to identify additional opportunities for providing intensive and
ongoing support. (Note: family nurses make frequent home visits.)
Work in partnership with agencies that support women who have complex
social and emotional needs. This includes substance misuse services,
youth and teenage pregnancy support and mental health services.
Recommendation 7 Partners and others in the household who
smoke
Context
Interventions which are effective with the general population will not
necessarily work with the partners of women who are pregnant. For example,
simply providing booklets, self-help guidance or media education campaigns
is not effective with this group around the time of pregnancy.
Who should take action?
NHS Stop Smoking Services.
What action should they take?
Provide clear advice about the danger that other people’s tobacco smoke
poses to the pregnant woman and to the baby – before and after birth.
6
This is an edited extract from a recommendation that appears in ‘Identifying and supporting
people most at risk of dying prematurely’ NICE public health guidance 15. It does not
constitute a change to the original recommendation.
Page 18 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Recommend not smoking around the pregnant woman, mother or baby.
This includes not smoking in the house or car.
Offer partners who smoke help to stop using a multi-component
intervention that comprises three or more elements and multiple contacts.
Discuss with them which options to use – and in which order, taking into
account7:
their preferences
contra-indications and the potential for adverse effects from
pharmacotherapies such as NRT
the likelihood that they will follow the course of treatment
their previous experience of smoking cessation aids.
Do not favour one medication over another. Together, choose the one that
seems most likely to succeed taking into account the above 8.
Recommendation 8 Training to deliver interventions
Who should take action?
Commissioners of NHS Stop Smoking Services.
Maternity services.
Professional bodies and organisations.
NHS Centre for Smoking Cessation and Training.
Other providers of smoking cessation training which meets the national
standard.
7
This is an edited extract from a recommendation that appears in ‘Smoking cessation
services’ NICE public health guidance 10. It does not constitute a change to the original
recommendation.
8
This is an edited extract from a recommendation that appears in ‘Smoking cessation
services’ NICE public health guidance 10. It does not constitute a change to the original
recommendation.
Page 19 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
What action should they take?
Ensure all midwives who deliver intensive stop-smoking interventions
(one-to-one or group support – levels 2 and 3) are trained to the same
standard as NHS stop-smoking advisers. The minimum standard for these
interventions is set by the NHS Centre for Smoking Cessation and
Training9. They should also be provided with additional, specialised
training and offered ongoing support and training updates10.
Ensure all midwives who are not specialist stop-smoking advisers are
trained to assess and record people’s smoking status and their readiness
to quit. They should also know about the health risks of smoking and the
benefits of quitting – and understand why it can be difficult to stop. In
addition, they should know about the treatments that can help people to
quit and how to refer them to local services for treatment. (Acquisition of
this knowledge and skill set is part of level 1 training in brief stop-smoking
interventions11. Please note, midwives are not advised to carry out brief
interventions with pregnant women. However, they are advised to use
these skills to initiate a referral to NHS Stop Smoking Services.)
Ensure midwives and NHS stop-smoking specialist advisers who work with
pregnant women:
know how to ask them questions in such a way that
encourages them to be open about their smoking
always recommend quitting rather than cutting down
have received accredited training in the use of CO monitors.
Ensure brief stop-smoking interventions (level 1) and intensive one-to-one
and group support to stop smoking (levels 2 and 3) are incorporated into
pre- and post-registration midwifery training and midwives’ continuing
professional development, as appropriate.
9
www.ncsct.co.uk/
10
For information about the NHS Centre for Smoking Cessation and Training’s forthcoming
specialist module go to www.ncsct.co.uk
11
For the national standard for level 1 see ‘Standard for training in smoking cessation
treatments’ (www.nice.org.uk/page.aspx?o=502591) or future updates from the NHS Centre
for Smoking Cessation and Training.
Page 20 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Ensure all healthcare and other professionals who work with the target
group are trained in the same skills – and to the same standard – as those
required of midwives who are not specialist smoking cessation advisers.
This includes: GPs, practice nurses, health visitors, obstetricians,
paediatricians, sonographers, midwives (including young people’s lead
midwives), family nurses and those working in fertility clinics, dental
facilities and community pharmacies. It also includes those working in
youth and teenage pregnancy services, children’s centres, social services
and voluntary and community organisations.
Ensure all the healthcare and other professionals listed in the previous
bullet:
know what support local NHS Stop Smoking Services offer
and how to refer the women being targeted
understand the impact that smoking can have on a woman
and her unborn child
understand the dangers of exposing a pregnant woman and
her unborn child – and other children – to secondhand smoke.
Ensure all training in relation to smoking and pregnancy addresses the:
barriers that some professionals may feel they face when
trying to tackle smoking with a pregnant woman (for example,
they may feel that broaching the subject might damage their
relationship)
important role that partners and ‘significant others’ can play in
helping a woman who smokes and is pregnant (or who has
recently given birth) to quit. This includes the need to get
them to consider quitting if they themselves smoke.
2 Public health need and practice
According to research conducted by the British Market Research Bureau, in
2005 nearly a third (32%) of mothers in England smoked in the 12 months
before or during pregnancy. Although nearly half (49%) gave up before the
birth, three in ten (30%) were smoking again less than a year after giving birth.
Page 21 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
One in six (17%) continued to smoke throughout their pregnancy – one in ten
(11%) of them cut down the amount they smoked (British Market Research
Bureau 2007).
However, other research (including studies which had biochemically validated
smoking status) suggests that the proportion of women smoking before or
during pregnancy is higher than this (French et al. 2007; Lawrence et al. 2005;
Owen and McNeill 2001). In addition, studies using biochemical measures of
exposure to tobacco smoke suggest that their intake of toxins is not actually
reduced – even when they said they had cut down (Lawrence et al. 2003).
In 2005, almost four in ten mothers in England (38%) lived in a household
where at least one person smoked during their pregnancy. In most cases the
person who smoked was the mother’s partner. A sizeable minority did give up
after the woman gave birth: 15% were not smoking when the baby was aged
4–10 weeks and by the time the baby was aged 4–6 and 8–10 months almost
a quarter (24%) had quit (British Market Research Bureau 2007).
Almost half of all children in the UK are exposed to tobacco smoke at home
(Jarvis et al. 2000).
Health risks
Smoking during pregnancy can cause serious pregnancy-related health
problems. These include: complications during labour and an increased risk of
miscarriage, premature birth, still birth, low birth-weight and sudden
unexpected death in infancy (Royal College of Physicians 1992). Smoking
during pregnancy also increases the risk of infant mortality by an estimated
40% (Department of Health 2007).
The total annual cost to the NHS of smoking during pregnancy is estimated to
range between £8.1 and £64 million for treating the resulting problems for
mothers and between £12 million and £23.5 million for treating infants (aged
0–12 months) (Godfrey et al. 2010).
Children exposed to tobacco smoke in the womb are more likely to experience
wheezy illnesses in childhood. In addition, infants of parents who smoke are
Page 22 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
more likely to suffer from serious respiratory infections (such as bronchitis and
pneumonia), symptoms of asthma and problems of the ear, nose and throat
(including glue ear). Exposure to smoke in the womb is also associated with
psychological problems in childhood such as attention and hyperactivity
problems and disruptive and negative behaviour (Button et al. 2007). In
addition, it has been suggested that smoking during pregnancy may have a
detrimental effect on the child’s educational performance (Batstra et al. 2003).
Key factors
Smoking during pregnancy is strongly associated with a number of factors
including age and social economic position.
Mothers aged 20 or under are five times more likely than those aged 35 and
over to have smoked throughout pregnancy (45% and 9% respectively)
(British Market Research Bureau 2007). Mothers in routine and manual
occupations are more than four times as likely to smoke throughout
pregnancy – compared to those in managerial and professional occupations
(29% and 7% respectively) (British Market Research Bureau 2007).
Pregnant women are also more likely to smoke if they are less educated, live
in rented accommodation and are single or have a partner who smokes.
Almost nine in ten mothers (87%) who were smoking before or during their
pregnancy said they received some type of advice or information about the
habit (British Market Research Bureau 2007).
Mothers who had only been advised to give up were much more likely to quit
– compared with those who were advised to cut down (36% and 8%
respectively). Mothers who were only advised to cut down were more likely to
take this option (69%) – less than 1% tried to quit. Mothers who received
mixed messages (to stop completely and cut down) were much more likely to
cut down rather than give up completely (58% and 14% respectively) (British
Market Research Bureau 2007). In addition, women with partners who smoke
find it harder to quit and are more likely to relapse if they do manage to quit
(Fang et al. 2004).
Page 23 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
3 Considerations
The Public Health Interventions Advisory Committee (PHIAC) took account of
a number of factors and issues when developing the recommendations.
3.1 PHIAC recognised that many of the women most likely to smoke
during pregnancy live in circumstances which make it difficult for
them to quit the habit. It believes that strategies which seek to
address the wider socioeconomic factors linked to smoking would
increase their chances of success.
3.2 The role of the family is important. The attitude of the family,
including the woman’s partner, towards smoking can have an effect
on her smoking behaviour (and her health, if they smoke).
3.3 A range of effective interventions and services, such as NHS Stop
Smoking Services, are available to help people quit smoking.
Nevertheless, only a small number of women take up the offer of
help during pregnancy or after childbirth. PHIAC believes a range
of local approaches are needed to increase the number of these
women who are referred to the services and who receive help.
3.4 PHIAC noted that the smoking, nicotine and pregnancy (SNAP)
randomised control trial is currently testing the efficacy and safety
of using nicotine patches with pregnant women. The results are
due in 2011.
3.5 In studies, biochemical measures of carbon monoxide (CO) levels
showed that women who said they had reduced the amount they
smoked during pregnancy did not necessarily reduce their
exposure to toxins. Additional evidence highlights the importance
for a woman who is pregnant to quit smoking altogether – rather
than just cutting down. This includes research showing that children
are more likely to take up the habit if their parents smoke and data
on the damage – for both mother and child – associated with
continued exposure to secondhand smoke.
Page 24 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
3.6 Women who are pregnant may receive mixed messages from
health professionals about the benefits of cutting down as opposed
to quitting smoking altogether.
3.7 US-based trials show that financial incentives are an effective way
to encourage women who are pregnant to quit smoking. However,
rigorous UK-based research is needed to take account of any
cultural differences. The committee acknowledge that there is a
need to avoid a proliferation of local evaluations which may be
insufficiently powered or inappropriately designed to determine
whether or not incentives are effective
3.8 PHIAC was concerned to ensure health professionals in contact
with pregnant women who smoke are not put off if their first offer of
help to quit smoking is refused. As a result, the recommendations
emphasise the importance of offering help to stop smoking
throughout the pregnancy and beyond.
3.9 Professional barriers to tackling smoking among women who are
pregnant or who have recently given birth include: lack of time, lack
of resources and concern about jeopardising the professional
relationship with the client. PHIAC believed that these issues can
be addressed by referring the women for specialist help as part of
normal practice.
3.10 Although many women quit smoking during their pregnancy,
relapse rates are high and most start smoking again within 6
months of giving birth. PHIAC noted that the types of interventions
that had been studied had not been effective in preventing relapse.
3.11 None of the studies of women who were pregnant included
household members other than the partner (that is, the expectant
father).
3.12 PHIAC acknowledged that encouraging practitioners to refer all
pregnant women who smoke – even those who are currently
Page 25 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
unwilling to consider quitting – may create a need for additional
stop-smoking resources. It also acknowledged that initially, at least,
this may also lead to lower success rates. Nevertheless, the
committee believed that higher referral rates are important in
tackling smoking in pregnancy.
3.13 The cost-effectiveness model showed that interventions to
encourage women who are pregnant to quit smoking were cost
effective (in the main, they were more effective and less costly than
not intervening). However, due to insufficient data, not all the
effects of smoking during pregnancy were modelled. For instance,
the model did not include the impact on subsequent infant morbidity
and quality of life or healthcare costs for children aged over 5
years. If these factors had been included in the analysis, PHIAC
believes the interventions would have probably been even more
cost effective.
4 Implementation
NICE guidance can help:
NHS organisations, social care and children's services meet the
requirements of the DH's 'Operating framework for 2008/09' and
'Operational plans 2008/09–2010/11'.
NHS organisations, social care and children's services meet the
requirements of the Department of Communities and Local Government's
'The new performance framework for local authorities and local authority
partnerships'.
National and local organisations within the public sector meet government
indicators and targets to improve health and reduce health inequalities.
Local authorities fulfil their remit to promote the economic, social and
environmental wellbeing of communities.
Page 26 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Local NHS organisations, local authorities and other local public sector
partners benefit from any identified cost savings, disinvestment
opportunities or opportunities for re-directing resources.
Provide a focus for multi-sector partnerships for health and wellbeing, such
as local strategic partnerships.
NICE has developed tools to help organisations put this guidance into
practice. For details see our website at www.nice.org.uk/guidance/PH26
5 Recommendations for research
The Public Health Interventions Advisory Committee (PHIAC) recommends
that the following research questions should be addressed. It notes that
'effectiveness' in this context relates not only to the size of the effect, but also
to cost effectiveness and duration of effect. It also takes into account any
harmful/negative side effects.
1. Within a UK context, are incentives an acceptable, effective and cost-
effective way to help women who smoke to quit the habit when they are
pregnant or after they have recently given birth? Compared with current
services, do they attract more women who smoke, do they lead to more
of them completing the stop-smoking programme and do more of them
quit for good? What level and type of incentive works best and are there
any unintended consequences?
2. What are the most effective and cost-effective ways of preventing
women who have quit smoking from relapsing, either during pregnancy
or following childbirth?
3. What factors explain why some women who become pregnant
spontaneously quit smoking? How do social factors (such as the
smoking status of friends and family) affect any spontaneous or assisted
attempt to quit smoking?
Page 27 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
4. How can more women (including teenagers) who smoke and are
pregnant or who have recently given birth be encouraged to use stop-
smoking services?
5. Within a UK context, which types of self-help materials (including new
media) help women who smoke to quit when they are pregnant or after
they have recently given birth?
6. What are the most effective and cost-effective ways of helping particular
groups of people who smoke to stop around the time of pregnancy?
These groups include the partners of pregnant women, pregnant
teenagers and pregnant women who live in difficult circumstances.
More detail on the gaps in the evidence identified during development of this
guidance is provided in appendix D.
6 Updating the recommendations
This guidance will be reviewed at 3 and 5 years after publication to determine
whether all or part of it should be updated. Information on the progress of any
update will be posted at www.nice.org.uk/guidance/PH26
7 Related NICE guidance
Published
School-based interventions to prevent smoking. NICE public health guidance
23 (2010). Available from www.nice.org.uk/guidance/PH23
Antenatal care: routine care for the healthy pregnant woman. NICE clinical
guideline 62 (2008). Available from www.nice.org.uk/guidance/CG62
Identifying and supporting people most at risk of dying prematurely. NICE
public health guidance 15 (2008). Available from
www.nice.org.uk/guidance/PH15
Smoking cessation services. NICE public health guidance 10 (2008).
Available from www.nice.org.uk/guidance/PH10
Page 28 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Community engagement. NICE public health guidance 9 (2008). Available
from www.nice.org.uk/guidance/PH9
Behaviour change. NICE public health guidance 6 (2007). Available from
www.nice.org.uk/guidance/PH6
Workplace interventions to promote smoking cessation. NICE public health
guidance 5 (2007). Available from www.nice.org.uk/guidance/PH5
Brief interventions and referral for smoking cessation in primary care and
other settings. NICE public health guidance 1 (2006). Available from
www.nice.org.uk/guidance/PH1
Postnatal care: routine postnatal care of women and their babies. NICE
clinical guideline 37 (2006). Available from
http://www.nice.org.uk/guidance/CG37
Under development
Weight management in pregnancy and after childbirth. NICE public health
guidance (publication expected July 2010)
Pregnancy and complex social factors. NICE clinical guideline (publication
expected August 2010)
8 References
Batstra L, Hadders-Algra M, Neeleman J (2003) Effect of antenatal exposure
to maternal smoking on behavioural problems and academic achievement in
childhood. Early Human Development 75: 21–33
British Market Research Bureau (2007) Infant feeding survey 2005. A survey
conducted on behalf of the Information Centre for Health and Social Care and
the UK Health Departments. Southport: The Information Centre
Button TMM, Maughan B, McGuffin P (2007) The relationship of maternal
smoking to psychological problems in the offspring. Early Human
Development 83 (11): 727–32
Page 29 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Department of Health (2007) Review of the health inequalities infant mortality
PSA target. London: Department of Health
Fang WL, Goldstein AO, Butzen AY et al. (2004) Smoking cessation in
pregnancy: A review of postpartum relapse prevention strategies. The Journal
of the American Board of Family Medicine 17: 264–75
French GM, Groner JA, Wewers ME et al. (2007) Staying smoke free: an
intervention to prevent postpartum relapse. Nicotine and Tobacco Research 9
(6): 663–70
Godfrey C, Pickett KE, Parrot S et al. (2010) Estimating the costs to the NHS
of smoking in pregnancy for pregnant women and infants. York: Department
of Health Sciences, The University of York
Jarvis MJ, Goddard E, Higgins V et al. (2000) Children’s exposure to passive
smoking in England since the 1980s: cotinine evidence from population
surveys. BMJ 321: 343–5
Lawrence T, Aveyard P, Croghan E (2003) What happens to women’s self-
reported cigarette consumption and urinary cotinine levels in pregnancy?
Addiction 98: 1315–20
Lawrence T, Aveyard P, Cheng KK et al. (2005) Does stage-based smoking
cessation advice in pregnancy result in long-term quitters? 18-month
postpartum follow-up of a randomised controlled trial. Addiction 110: 107–16
Owen L, McNeill A (2001) Saliva cotinine as an indicator of cigarette smoking
among pregnant women. Addiction 96 (7): 1001–6
Royal College of Physicians (1992) Smoking and the young. London: Royal
College of Physicians
Page 30 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Appendix A Membership of the Public Health
Interventions Advisory Committee (PHIAC), the NICE
project team and external contractors
Public Health Interventions Advisory Committee
NICE has set up a standing committee, the Public Health Interventions
Advisory Committee (PHIAC), which reviews the evidence and develops
recommendations on public health interventions. Membership of PHIAC is
multidisciplinary, comprising public health practitioners, clinicians, local
authority officers, teachers, social care professionals, representatives of the
public, academics and technical experts as follows.
Professor Sue Atkinson CBE Independent Consultant and Visiting
Professor, Department of Epidemiology and Public Health, University College
London
Mr John F Barker Associate Foundation Stage Regional Adviser for the
Parents as Partners in Early Learning Project, DfES National Strategies
Professor Michael Bury Emeritus Professor of Sociology, University of
London. Honorary Professor of Sociology, University of Kent
Professor K K Cheng Professor of Epidemiology, University of Birmingham
Ms Joanne Cooke Programme Manager, Collaboration and Leadership in
Applied Health Research and Care for South Yorkshire
Mr Philip Cutler Forums Support Manager, Bradford Alliance on Community
Care
Ms Lesley Michele de Meza Personal, Social, Health and Economic (PSHE)
Education Consultant, Trainer and Writer
Page 31 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Professor Ruth Hall CB Public Health Physician; Visiting Professor at the
University of the West of England.
Ms Amanda Hoey Director, Consumer Health Consulting Limited
Mr Alasdair J Hogarth Head Teacher, Archbishops School, Canterbury
Dr Ann Hoskins Director, Children, Young People and Maternity, NHS North
West
Ms Muriel James Secretary, Northampton Healthy Communities
Collaborative and the King Edward Road Surgery Patient Participation Group
Dr Matt Kearney General Practitioner, Castlefields, Runcorn. GP Public
Health Practitioner, Knowsley PCT
CHAIR Professor Catherine Law Professor of Public Health and
Epidemiology, UCL Institute of Child Health
Mr David McDaid Research Fellow, Department of Health and Social Care,
London School of Economics and Political Science
Mr Bren McInerney Community Member
Professor Susan Michie Professor of Health Psychology, BPS Centre for
Outcomes Research and Effectiveness, University College London
Professor Stephen Morris Professor of Health Economics, Department of
Epidemiology and Public Health, University College London
Dr Adam Oliver RCUK Senior Academic Fellow, Health Economics and
Policy, London School of Economics
Dr Mike Owen General Practitioner, William Budd Health Centre, Bristol
Dr Toby Prevost Reader in Medical Statistics, Department of Public Health
Sciences, King's College London
Ms Jane Putsey Lay Member, Registered Tutor, Breastfeeding Network
Page 32 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Dr Mike Rayner Director, British Heart Foundation Health Promotion
Research Group, Department of Public Health, University of Oxford
Mr Dale Robinson Chief Environmental Health Officer, South
Cambridgeshire District Council
Ms Joyce Rothschild Children’s Services Improvement Adviser, Solihull
Metropolitan Borough Council
Dr Tracey Sach Senior Lecturer in Health Economics, University of East
Anglia
Dr David Sloan Retired Director of Public Health
Professor Stephanie Taylor Professor of Public Health and Primary Care,
Centre for Health Sciences, Barts and The London School of Medicine and
Dentistry
Dr Stephen Walters Reader, Medical Statistics, University of Sheffield
Dr Dagmar Zeuner Joint Director of Public Health, Hammersmith and Fulham
PCT
Expert co-optees to PHIAC:
Doris Gaga Smoking Cessation Counsellor, Southwark Stop Smoking
Services for Pregnant Women/Parents
Susie Hill Health Campaign Manager, Tommy’s (the baby charity)
Richard Windsor Professor of Public Health, George Washington University
Medical Centre
NICE project team
Mike Kelly CPHE Director
Antony Morgan Associate Director
Lesley Owen Lead Analyst and Technical Adviser (Health Economics)
Page 33 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Dylan Jones Analyst
Karen Peploe Analyst
Emma Doohan Project manager
Palida Teelucknavan Coordinator
Sue Jelley Senior Editor
Alison Lake Editor
External contractors
Evidence reviews
Review 1: 'Which interventions are effective and cost effective in encouraging
the establishment of smokefree homes?' was carried out by the School of
Health and Related Research (ScHARR), University of Sheffield. The principal
authors were: Susan Baxter, Lindsay Blank, Louise Guillaume, Josie Messina,
Emma Everson-Hock and Julia Burrows.
Review 2: 'Factors aiding delivery of effective interventions' was carried out by
ScHARR, University of Sheffield. The principal authors were: Susan Baxter,
Lindsay Blank, Louise Guillaume, Josie Messina, Emma Everson-Hock and
Julia Burrows.
Review 3: 'The health consequences of pregnant women cutting down as
opposed to quitting' was carried out by ScHARR, University of Sheffield. The
principal authors were: Susan Baxter, Lindsay Blank, Louise Guillaume, Josie
Messina, Emma Everson-Hock and Julia Burrows.
Cost effectiveness
'The economic analysis of interventions for smoking cessation aimed at
pregnant women' was carried out by the York Health Economics Consortium,
University of York. The principal author was Matthew Taylor.
Page 34 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Fieldwork
The fieldwork ’Consultation on NICE draft recommendations on quitting
smoking in pregnancy and after childbirth: Report to the National Institute for
Health and Clinical Excellence’ was carried out by Greenstreet Berman Ltd.
Expert reports
Expert report 1: 'The effectiveness of smoking cessation interventions during
pregnancy: a briefing paper' was carried out by the UK Centre for Tobacco
Control Studies. The principal authors were: Linda Bauld and Tim Coleman.
Expert report 2: 'Interventions to improve partner support and partner
cessation during pregnancy' was carried out by the Centre of Excellence for
Women's Health, British Columbia. The principal authors were: Natalie
Hemsing, Renee O’Leary, Katharine Chan, Chizimuzo Okoli and Lorraine
Greaves.
Expert report 3: 'Rapid review of interventions to prevent relapse in pregnant
ex-smokers' was carried out by Barts and The London School of Medicine and
Dentistry, London. The principal authors were: Katie Myers, Oliver West and
Peter Hajek.
Page 35 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Appendix B Summary of the methods used to develop
this guidance
Introduction
The reviews, commissioned reports and economic modelling include full
details of the methods used to select the evidence (including search
strategies), assess its quality and summarise it.
The minutes of the Public Health Interventions Advisory Committee (PHIAC)
meetings provide further detail about the Committee’s interpretation of the
evidence and development of the recommendations.
All supporting documents are listed in appendix E and are available at
www.nice.org.uk/guidance/PH26
Page 36 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
Guidance development
The stages involved in developing public health intervention guidance are
outlined in the box below.
1. Draft scope released for consultation
2. Stakeholder meeting about the draft scope
3. Stakeholder comments used to revise the scope
4. Final scope and responses to comments published on website
5. Evidence reviews and economic modelling undertaken and submitted to
PHIAC
6. PHIAC produces draft recommendations
7. Draft guidance (and evidence) released for consultation and field testing
8. PHIAC amends recommendations
9. Final guidance published on website
10. Responses to comments published on website
Key questions
The key questions were established as part of the scope. They formed the
starting point for the reviews of evidence and were used by PHIAC to help
develop the recommendations. The overarching questions were:
1. Which interventions are effective and cost effective in helping women to
quit smoking immediately before or during pregnancy and following
childbirth?
2. Which interventions are effective and cost effective in encouraging
partners (and ‘significant others’) help a woman quit smoking during her
pregnancy and following childbirth?
Page 37 of 58NICE public health guidance 26: Quitting smoking in pregnancy and following
childbirth
3. Which interventions are effective and cost effective in preventing women
who have quit smoking to take up the habit again during pregnancy and
following childbirth?
4. Which interventions are effective and cost-effective in encouraging
partners (and 'significant others') who smoke to stop smoking
themselves?
5. Which interventions are effective and cost effective in encouraging the
establishment of smokefree homes?
6. What factors aid delivery of effective interventions? What are the barriers
to successful delivery?
7. What are the health consequences of pregnant women cutting down on
their cigarette consumption as opposed to quitting?
These questions were made more specific for each review (see reviews for
further details).
Reviewing the evidence
Effectiveness reviews
Three reviews of effectiveness were conducted.
Identifying the evidence
The following databases were searched from 1990 to 2009 for: interventions
that encourage smokefree homes; factors which help or discourage pregnant
women who smoke to use smoking cessation interventions; and the health
consequences of pregnant women cutting down as opposed to quitting.
Applied Social Sciences Index and Abstracts (ASSIA)
British Nursing Index
Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Embase
Maternity and Infant Care
Page 38 of 58You can also read
